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Home , Anterior jugular vein, Axillary vein, Cystic vein, Lumbar veins, Median sacral vein, Popliteal fossa

Anatomy of large vessels –

Lecture 3 Please check our Editing File { َوَم نْ يَ َت َو َ ّكْ عَ َلْ ا َ هّْلل فَهُ َوْ َح س ْ ُب ُهْ} هذا العمل ال يغني عن المصدر األساسي للمذاكرة Objectives

● Define the veins, and understand the general principle of the venous system. ● Describe the superior & inferior Vena Cava (formation & their tributaries) Head & & Upper & lower limbs ● List major veins and their (formation & tributaries in the body) ● Describe the Portal (formation & tributaries in the body) ● Describe the Portocaval Anastomosis (formation, sites & tributaries in the body) Veins

● Veins are blood vessels that bring blood back to the . ● All veins carry deoxygenated blood - with the exception of the pulmonary veins (open in the left atrium) and (during fetal development).

Vein can be classified in 2 ways based on

Location Circulation

Superficial veins: Veins of the systemic Deep veins: found close to the surface of circulation: Veins of the portal deeper in the body the body Superior and Inferior circulation: -With corresponding -NO corresponding vena cava with their Portal vein arteries tributaries Vena Cava ONLY in boy’s slides

● They are two large veins that return deoxygenated blood from the body into the heart. ● There are the and the inferior vena cava. ● Both empty into the right atrium. ● They are located slightly off-center toward the right side of the body. Superior vena cava

❖ The superior vena cava is above the heart of the right and left ’اتحاد“ Formed by the union ❖ Brachiocephalic veins. -Brachiocephalic veins are formed by the union of internal jugular and subclavian veins. ❖ Drains venous blood from : Head & neck, Thoracic wall ,Upper limbs ❖ It Passes downward and enter the right atrium. ❖ Receives azygos vein on the posterior aspect just before it enters the heart. Veins of Head & Neck Superficial Veins of Head & Neck

Superficial Veins ❖ External : - Lies superficial to the sternomastoid muscle External Jugular veins - Formed by the union of and . Anterior jugular veins - Begins just behind the angle of by Deep Veins union of posterior auricular vein with the posterior division of Internal Jugulars veins. retromandibular vein. - It passes down the neck and it is the only tributary.

Deep of the .

- It drains blood from: Superficial 1- Outside of the 2- Deep parts of the face. Superficial Veins of head & neck

❖ Anterior jugular veins: - It begins in the upper part of the neck by the union of the submental veins. - It descends close to the median line of the neck, medial to the sternomastoid. - At the lower part of the neck, it passes laterally beneath sternomastoid muscle to drain into the . - Just above the sternum the two anterior jugular veins communicate by a transverse vein to form the jugular arch. Deep Veins of head & neck ❖ : - Drains blood from the brain,face, head & neck. - It descends in the neck along with the internal and common carotid arteries and vagus nerve, within the . - Joins the subclavian vein to form the . - Tributaries ‘branches’: 1-Superior 2-Lingual 3-Facial 4-Pharyngeal. 5-Occipital veins 6- (). - These veins drain blood from anterior face, , thyroid, esophagus, larynx, and muscles of the neck. Venous disorder ONLY in boy’s slides

❖ INFARCTION : - Refers to tissue death (necrosis) that is caused by a local lack of oxygen due to obstruction of the tissue's blood supply ❖ SINUS : - SSS thrombosis ● ● Can complicates infection

- thrombosis ● As a complication of infection in the dangerous area of the face - Obstruction of venous drainage of the brain leads to Cerebral swelling () and raised Intracranial Pressure. Veins of

Veins of Upper Limbs

Superficial Veins

Cephalic vein

Basilic vein

Deep Veins

Venae commitantes

Axillary vein 1-Superficial Vein Veins of upper limbs Cephalic vein ➔ Arize from the dorsal venous network of the hand ➔ Ascends in the superficial on the lateral side of the biceps (antero-lateral aspect of the upper limb, passing anteriorly at the elbow). ➔ At the shoulder, the cephalic vein travels between the deltoid and pectoralis major muscles to enters the region via the calvipectoral triangle. ➔ Drains into the . (note that Cephalic is a tributary of the axillary vein)

Basilic vein ➔ Originate from the dorsal venous network of the hand. ➔ Ascends in the superficial fascia on the medial side of the biceps. ➔ Halfway up the , it pierces the deep fascia ➔ At the lower border of the teres major it joins the venae comitantes of the brachial to form the Axillary vein. Veins of upper limbs 2- Deep Veins The deep veins of the upper limb are situated underneath the deep fascia. Venae Commitantes (paired veins that accompany one artery) ➔ Which accompany all the large arteries and are usually in pairs. ➔ The are the largest in size, and are situated either side of the brachial artery. ➔ Ulnar and radial veins are vena comitantes of ulnar and radial arteries. ➔ The pulsations of the brachial artery assists the venous return. ➔ Perforating veins run between the deep and superficial veins of the upper limb, connecting the two systems together.

Axillary Vein ➔ Formed by the union of basilic vein and the venae comitantes (brachial veins) of the brachial artery. Veins of upper limbs ONLY in boy’s slides 2- Deep Veins Subclavian Vein ➔ Each subclavian vein is a continuation of the axillary vein and runs from the outer border of the first to the medial border of anterior scalene muscle. ➔ It then joins with the internal jugular vein to form the brachiocephalic vein. ➔ The subclavian vein follows the . ➔ The right and left brachiocephalic veins form superior vena cava that enters right atrium. anterior to the middle

‘ Pulse points in the upper limb ONLY in boy’s slides

AXILLARY PULSE Located inferiorly of the lateral wall of the axilla.

BRACHIAL PULSE Located on the inside of the upper arm near the elbow, frequently used in place of carotid pulse in infants (brachial artery). ONLY in boy’s slides ULNAR PULSE Located on the medial of the wrist (ulnar artery).

RADIAL PULSE Located on the lateral of the wrist (radial artery). It can also be found in the anatomical snuff box. Clinical significance ONLY in boy’s slides

VENEPUNCTURE ● The practice of obtaining intravenous access. This can be for intravenous therapy or obtaining a blood sample. ● The main vein used in is the median cubital vein. ● It is a superficial vein that is situated anteriorly at the cubital region. ● It is commonly used due to its accessible and superficial position. Inferior vena cava

● Drains most of the blood from the body below the diaphragm to the right atrium. ● Formed by the union of the two common iliac veins behind the right common iliac artery at the level of the 5th lumbar vertebra. ● Ascends on the right side of the . ● Pierces the central tendon of diaphragm at the level of the 8th thoracic vertebra. ● It is the largest vein in the . ● Travels up alongside with blood from lower part of the body. Tributaries of Inferior Vena Cava IMPORTANT

1. Two common iliac veins 2. 3. Four paired 4. Right (the left vein drains into the left ) 5. Paired renal veins 6. Right suprarenal vein (the left vein drains into the left renal vein) 7. Hepatic veins 8. Paired inferior phrenic veins. Veins of lower limb

Superficial veins Deep veins ● Form a network in the ● Comprise the venae subcutaneous tissue. comitantes, which accompany ● Pattern is variable all the large arteries, usually in ● They are the tributaries of the: pairs. - Great (long) saphenous vein ● Venae comitantes unite to - Small (short) saphenous vein form the , which continues as the . ● Deep veins Receive blood from superficial veins through perforating veins. ● Including: o Anterior and posterior tibial veins o Popliteal vein o Femoral vein Superficial veins of lower limb

Great saphenous vein ● The longest vein ● Begins from the medial end of the dorsal venous arch of the foot ● Passes upward in front of the medial malleolus with the saphenous nerve. ● Then it ascends in accompany with the saphenous nerve in the superficial fascia over the medial side of the leg ● Ascends obliquely upwards, and lies behind the medial border of the patella. ● Passes behind the and curves forward around the medial side of the thigh. ● Hooks through the lower part of the saphenous opening in the deep fascia to join the femoral vein about 1.5 in. (4 cm) below and lateral to the pubic tubercle. Superficial veins of lower limb ONLY in girl’s slides

Great saphenous vein ● It is connected to the small saphenous vein by one or two branches that pass behind the knee. ● It is connected to the deep veins by numerous perforating veins.

● The perforating veins have valves which allow blood flow from superficial to deep veins. ● It is clinically significant in coronary bypass surgery and in intravenous delivery of fluids due to venous collapse.

● The great saphenous vein is used in venous grafting and saphenous vein cutdown may be necessary for inserting the neddle or canula (take care of the saphenous nerve). Superficial veins of lower limb

Small saphenous vein ● Arises from the lateral end of the dorsal venous arch. ● Ascends behind the lateral malleolus in company with the . ● Ascends along the lateral border of the tendocalcaneus and then runs up to the middle of the back of the leg.

● Pierces the deep fascia in the lower part of the popliteal fossa ● Drains into the popliteal vein ● Has numerous valves along its course. ● Anastomosis freely with great saphenous vein Veins of foot & leg ONLY in boy’s slides

● The plantar aspect of the foot, medial and lateral plantar veins arise. These veins combine to form the posterior tibial and fibular veins.

● The posterior tibial vein accompanies the , entering the leg posteriorly to the medial malleolus.

● On the posterior surface of the knee, the anterior tibial, posterior tibial and fibular veins unite to form the popliteal vein. Veins of foot & leg ONLY in boy’s slides Popliteal vein Femoral vein ● Comprise the venae comitantes, ● The femoral vein is a which accompany popliteal that accompanies the . artery in the femoral sheath. ● Formed by the unite of anterior, ● It is a continuation of the popliteal posterior tibial and fibluar veins. vein. ● Popliteal vein then continues ● Ends at the inferior margin of the as the femoral vein. inguinal ligament, where it ● Receive blood from superficial becomes the external . through perforating veins. ● External iliac join internal iliac to form common iliac veins. ● Both right and left common iliac veins form inferior vena cava that drains the entire low part of the body. ● Inferior vena cava drains into right atrium. Pulse points in the lower limb ONLY in boy’s slides

FEMORAL PULSE Located in the inner thigh, at the mid-inguinal point, halfway between the pubic symphysis and anterior superior iliac spine (femoral artery )

POPLITEAL PULSE Located above the knee in the popliteal fossa. The patient bends the knee at approximately 124°, and the physician holds it in both hands to find the in the pit behind the knee (Popliteal artery).

DORSALIS PEDIS PULSE Located on top of the foot, immediately lateral to the extensor of hallucis longus (dorsalis pedis artery). Mechanism of Venous Return from LL (FYI) (FYI = for your information) o Much of the saphenous blood passes from superficial to deep veins through the perforating veins. o The blood is pumped upwards in the deep veins by the contraction of the calf muscles (calf pump). o This action of calf pump is assisted by the tight sleeve of deep fascia surrounding these muscles. o If the valves in the perforating veins become incompetent, the direction of blood flow is reversed and the veins become varicosed. o Most common in posterior & medial parts of the lower limb, particularly in old people. Factors aming blood return ONLY in boy’s slides FACTORS AIMING BLOOD RETURN o Muscle Contraction: rhythmical contraction of limb muscles as occurs during normal locomotory activity (walking, running, swimming) promotes venous return by the muscle pump mechanism. o Respiratory Pump: during respiratory inspiration, the venous return increases because of a decrease in right atrial pressure. o Decreased Venous Compliance: sympathetic activation of veins decreases venous compliance, increases central venous pressure and promotes venous return. o Gravity: the effects of gravity on venous return seem paradoxical because when a person stands up hydrostatic forces cause the right atrial pressure to decrease and the venous pressure in the dependent limbs to increase. Thrombosis (DVT) ONLY in boy’s slides

● Occurs when a blood clot (thrombus) forms in one or more of the deep veins in your body, usually in your legs. can cause leg pain or swelling, but may occur without any symptoms. ● Deep vein thrombosis is a serious condition because blood clots in your veins can break loose, travel through your bloodstream and lodge in your , blocking blood flow (pulmonary embolism). Portal Circulation Portal Circulation o A portal venous system is a series of veins or that directly connect two beds (of & ). o Examples of such systems include the hepatic portal vein and hypophyseal portal system. Hepatic Circulation Hepatic Portal Vein o Drains blood from the and spleen to the liver. o It is formed by the union of the superior mesenteric and splenic veins behind the neck of pancreas. o Immediately before reaching the liver, the portal vein divides into right and left that enter the liver. o Tributaries: • Right and Left Gastric veins. • from the joins its right branch. • Paraumbilical veins that drain veins from anterior abdominal wall to the hepatic portal vein. Portocaval Anastomosis Portocaval Anastomosis o A portocaval anastomosis (also known as portal systemic anastomosis) is a specific type of anastomosis that occurs between the veins of portal circulation and those of systemic circulation (IVC). o The anastomotic channels become dilated (varicosed) in case of portal hypertension. Team 436 Sites of Portocaval Anastomosis Portocaval Anastomosis Site Associated condition Portal Vein Systemic Vein Esophageal branch of Lower end of esophagus Left gastric vein Esophageal Varices azygos vein Lower part of rectum (or Middle and inferior rectal Superior rectal vein Hemorrhoids upper part of anal canal) vein Paraumbilical region Paraumbilical veins Superficial epigastric vein Caput Medusae

Veins of the posterior Retroperitoneal Colic veins abdominal wall -- (retroperitoneal veins) Patent Umbilical vein + (intrahepatic portosystemic Inferior Vena Cava -- portal vein shunt) Patent ductus venosus (intrahepatic portosystemic shunt) : Portosystemic shunts may be congenital or may be acquired with diseases that cause portal hypertension. (Hepatomegaly, ascitis and signs of portal hypertension). There is some anastomosis between portal venous channels in the liver and Bare area of liver azygous system of veins above the diaphragm. MCQs

(1) All veins carry deoxygenated blood except: A) Pulmonary veins B) Umbilical vein C) Jugular vein D) A+B (4) Which one of the following is a tributary for the internal jugular vein ? (2) Which one of the following is receiving the A) azygos vein? B) Transverse cervical vein A) Superior vena cava B) Inferior vena cava C) Occipital veins C) Pulmonary veins D) Umbilical vein D)

(3) Which one of the following is not a superficial (5) Which one of the following is not a tributary vein? for the inferior vena cava? A) External jugular veins A) Median sacral vein B) Right B) Internal jugular veins gonadal vein C) Anterior jugular veins C) Inferior petrosal sinus D) Hepatic veins D) Posterior jugular veins MCQs

(6) If the valves in the ______become incompetent, the direction of blood flow is reversed and the veins become varicose: A) Femoralvein B) Perforating veins (9) The anastomotic channels of portocaval C) Popliteal vein D) Small Saphenous Vein become dilated (varicose) in case of: A) Portal hypertension B) Hypertension C) Portal hypotension D) Hypotension (7) Which one of these factors decrease the venous pressure? (10) Where is the anastomosis between portal A) Gravity venous channels in the liver and azygous system B) Decreased Venous Compliance of veins above the diaphragm? C) Muscle contraction A) Lower part of rectum D) Respiratory pump B) Retroperitoneal C) Lower end of esophagus (8) Cystic vein joins ______of portal vein? D) Bare area of liver A) Left branch B) Right branch C) A+B D) None of them Answers (1) D (6) B (2) A (7) A (3) B (8) B (4) C (9) A (5) C (10) D Team Members Team leader: Faisal Fahad Alsaif Team leader: Rawan Mohammad Alharbi Abdulaziz Al dukhayel Abeer Alabduljabbar Abdulelah Aldossari Afnan Almustafa Abdulrahman Alduhayyim Ahad Algrain Hamdan Aldossari Albandari Alshaye Fahad Alfaiz AlFhadah alsaleem Zeyad Al-khenaizan Ghaida Alsanad Abdullah Almeaither Lojain Azizalrahman Abduljabbar Al-yamane Majd AlBarrak Abdulmajeed Alwardi Maha barakah Abdulaziz Al-drgam Nouf Alotaibi Ali Alammari Rinad Alghoraiby Saleh Almoaiqel Wejdan Albadrani Majed Aljohani